Don’t Open Up to Poor Coding

Use Percutaneous Cholangiogram Codes That Work

By Subashini Ganesan, CPC
Percutaneous cholangiogram is the study of the biliary tract by a needle puncture rather than open access. It is performed to detect the condition and the therapeutic procedure for surgical treatment.
A common pathological condition that requires a percutaneous procedure is biliary obstruction. Some causes of benign biliary obstruction include: bile duct stones, stricture, sclerosing cholangitis, inflammatory processes, pancreatitis and infections, and HIV. Malignant causes may include carcinoma of the pancreas, cholangiocarcinoma, and metastatic disease. Cholesterol stones are the major cause of biliary obstruction.

When is Cholangiogram Performed?

If the patient has a biliary stone, a radiologist may treat the stone and alleviate the obstruction. Using diagnostic cholangiogram, the radiologist passes a needle through the liver into one of the intrahepatic bile ducts, injects the contrast, and reviews the images. The radiologist can detect blockage by viewing the flow of contrast fluoroscopically. You should report this procedure with 47500 Injection procedure for percutaneous transhepatic cholangiography and 74320 Cholangiography, percutaneous, transhepatic, radiological supervision and interpretation. If blockage is identified, the physician places a drainage tube to drain the excess bile.

Biliary Drainage

The physician may use an external, or an external and internal, biliary tract drainage system.
In external drainage, the bile is drained outside the body by placing a catheter into the bile duct. You may code this procedure with 47510 Introduction of percutaneous transhepatic catheter for biliary drainage and 75980 Percutaneous Transhepatic biliary drainage with contrast monitoring, radiological supervision and interpretation.
You may report the drainage codes twice if the physician performs both left and right side drainage. You should not append modifier 50 Bilateral Procedure to 47510. This procedure is not coded as bilateral, as the Centers for Medicare & Medicaid Services (CMS) guidelines. Instead, report two units of 47510. Some payers may require that you append modifier 59 Distinct Procedural Service to the second unit of 47510. Be sure to verify with local carriers for appropriate requirements.
For combined internal and external drainage, the physician advances a catheter into the bile duct and connects it to a drainage bag outside the body (external). The other end is connected to the duodenum to allow bile to drain internally into duodenum (internal). You may report a procedure of this type using 47511 Introduction of percutaneous transhepatic stent for internal and external biliary drainage) and 75982 Percutaneous placement of drainage catheter for combined internal and external biliary drainage in patients with an inoperable mechanical biliary obstruction, radiological supervision and interpretation.
If the physician performs diagnostic percutaneous transhepatic cholangiogram prior to catheter placement, you may report the procedure separately with 47500-59 and 74320.

T-tube Cholangiogram

The tube or catheter, percutaneous transhepatic T-tube, or external drainage may be left in the patient’s body over the extended period after drainage. The radiologist may study the existing catheter or tube by injecting fluoroscopic contrast and obtaining images. For this, report 47505 Injection procedure for cholangiography through an existing catheter (eg, percutaneous transhepatic or T-tube) and 74305 Cholangiography through existing catheter, radiological supervision and interpretation.
The physician may change the T-tube or drainage tube left in the biliary tract for drainage. To describe these procedures, call on 47525 Change of percutaneous biliary drainage catheter and 75984 Change of percutaneous tube or drainage catheter with contrast monitoring (eg, genitourinary system, abscess), radiological supervision and interpretation.
If the physician replaces the tube or catheter which runs across the liver to drain fluid, submit 47530 Revision and/or reinsertion of transhepatic tube with radiological supervision and interpretation code 75984. If the physician also performs cholangiogram prior to tube change, you may also code 47505 and 74305.

Stone Extraction

Physicians perform biliary duct stone extraction through the T-tube or drainage with or without an endoscope. The stone is removed from the bile duct through a previously created passage used for draining fluid from the biliary tract. The physician inserts a basket or snare into the bile duct to remove the stone. Choose 47630 Biliary duct stone extraction, percutaneous via T-tube tract, basket, or snare (eg, Burhenne technique) and 74327 Postoperative biliary tract calculus removal, percutaneous via T-tube tract, basket, or snare (eg, Burhenne technique), radiological supervision and interpretation for this service.
The physician may instead extract the stone percutaneously through the T-tube by inserting an endoscope into the biliary tract. For this type of extraction, cite code 47554 Biliary endoscopy, percutaneous via T-tube or other tract; with removal of calculus/calculi and either 74363 Percutaneous transhepatic dilation of biliary duct stricture with or without placement of stent, radiological supervision and interpretation or 75982 Percutaneous placement of drainage catheter for combined internal and external biliary drainage or of a drainage stent for internal biliary drainage in patients with an inoperable mechanical biliary obstruction, radiological supervision and interpretation, as appropriate.

Staged Procedures

Percutaneous biliary drainage procedures have a global period of 0-90 days. If the same physician performs a staged procedure during the global period of the original procedure, you should append modifier 58 Staged or related procedure or service by same physician during the postoperative period to the code for the subsequent procedure.
In the 47500-47630 range, only the following codes have a global period:

Global Period

For example, the physician introduces an endoscope directly into the bile duct, or through a T- tube or drainage tube which he inserted during a previous operation, and dilates the stricture to its normal shape. He then places a stent into the duct to maintain the passage. In this case, you would report 47556 Biliary endoscopy, percutaneous via T-tube or other tract, with dilation of biliary duct stricture(s) with stent.
If the physician performs the same procedure without a stent, you should instead call on 47555 Biliary endoscopy, percutaneous via T-tube or other tract; with dilation of biliary duct stricture(s) without stent.
With the endoscope inserted directly, or through the drainage tube, the physician can also take one or more tissue samples for examination and diagnosis. To claim this service, submit code 47553 Biliary endoscopy, percutaneous via T-tube or other tract; with biopsy, single or multiple. For the associated radiological interpretation, useeither 74363 or 75982, as appropriate.

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